Career Advice for Young Allergy Patients: A Systematic Review
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Background: One-third of all young persons entering the work force have a history of atopic disease. Occupationally induced allergy and asthma generally arise in the first few months on the job, while pre-existing symptoms tend to worsen. Young persons with a history of an atopic disease should receive evidence-based advice before choosing a career.
Methods: We systematically searched PubMed for cohort studies investigating the new onset of asthma, rhinitis, or hand eczema among job trainees from before the start of training and onward into the first few years on the job. The search revealed 514 articles; we read their abstracts and selected 85 full-text articles for further analysis. 24 of these met the inclusion criteria.
Results: According to present evidence, atopy and a history of allergic disease (allergic rhinitis, atopic dermatitis) are the main risk factors for occupationally induced disease. The predictive value of a personal history of allergic diseases for the later development of an occupationally induced disease varies from 9% to 64% in the studies we analyzed. It follows that only young people with severe asthma or severe atopic eczema should be advised against choosing a job that is associated with a high risk of allergy, e.g., hairdressing or working with laboratory animals. Young people with a history of other atopic diseases should be counseled about their individual risk profile.
Conclusion: In view of the relatively poor predictive value of pre-existing atopic disease, secondary prevention is particularly important. This includes frequent medical follow-up of the course of symptoms over the first few years on the job. If sensitization or allergic symptoms arise, it should be carefully considered whether exposure reduction will enable the apprentice to stay on the job.
Approximately one-third of adolescents aged between 14 and 17 years suffer from at least one atopic disease. The most common such diagnosis is allergic rhinitis (20%), followed by atopic dermatitis (16%), bronchial asthma (8%), and allergic contact eczema (6%) (1). As a result, every year in Germany approximately 170 000 young people with a history of atopic disease start an apprenticeship (1, e1). In many workplaces, they are exposed to allergens and irritants.
Due to the high prevalence of atopic diseases (history of IgE-mediated sensitization or manifest disease) and the common exposure to allergens and irritants at the workplace, asthma and dermatitis are among the most common occupational diseases in many industrialized countries (e2). Internationally, occupational exposure is responsible for approximately 16% of asthma cases (e3) and probably a high percentage of hand eczema cases in adults. There are more cases of disease exacerbated by exposure at work than new cases caused by the workplace (e4–e8). In Europe the incidence of occupational asthma has remained constant since 2007 (2). In 2014, a total of 26 058 cases of occupational skin or airway disease caused by chemicals or allergens were reported in Germany (e9). That year they were the third-most common type of recognized occupational disease, with 1161 cases, exceeded only by noise-induced hearing loss and asbestos-related diseases (e9). Part of the reason for the large difference between the numbers of reported and recognized cases is that in Germany an individual must cease the harmful work in order for such diseases to be recognized as occupational.
The incidence of diseases triggered by work is highest in the first 6 to 12 months of employment (3–10, e10–e18) and is correlated with the level and frequency of exposure. In addition, recent evidence suggests that work-related stress is also associated with asthma and allergies (e19).
Although individual, risk-related career advice would be an important step in preventing both early cessation of training and the development of occupational diseases, various studies show that few young people with prior atopic diseases take them into consideration when choosing an occupation, and that only 10% of these receive advice from a physician (11–13, e20–e23). Individual, risk-related career advice leads to better use of personal protective equipment (PPE) at work (12). This shows how important it is for young people with atopic diseases to receive evidence-based advice from a physician.
This article therefore aims to summarize the published data on risk factors for and the course of occupational asthma, rhinitis, and hand eczema in the first years of work and to use this data to develop strategies for evidence-based career advice.
A systematic search of the literature was performed in the PubMed database for the period from the beginning of 2011 onwards. The procedure followed is described in detail in the eBox.
For rhinitis and asthma, the position paper of the European Academy of Allergy and Clinical Immunology (EAACI) was used as the basis for selecting studies published before 2011 (14). It should be mentioned that this method entails the limitation that due to poor data quality (in particular, there were no unexposed groups) the authors of the position paper were able to make only expert-based recommendations, not evidence-based ones. For skin disorders, the literature search was expanded to cover the period from 1965 onwards.
This search strategy identified 908 articles, of which the authors viewed the titles. On this basis, 514 were selected for their abstracts to be viewed. Of these articles, 85 potentially suitable fulltexts were identified, of which 24 were considered relevant to this review.
Only 5 of the 15 publications concerning the airways presented the findings of prospective cohort studies in which individuals at the beginning of their careers had been observed before or from the beginning of exposure (6–10). These 5 also contained data on risk factors before the beginning of training (eBox, eTable 1). Two studies were conducted in the general population (6, 9); an additional study included a small, unexposed comparison group (8). A study by Acouetey et al. followed 251 bakery/pastry and hairdressing apprentices prospectively over 2 years, taking gnetic predictors of occupational asthma into account (10). One additional study was very small, with only 37 participants, and had a very short follow-up period, lasting only one year (7).
The other prospective cohort studies either examined the first years following the end of training (15) or did not exclusively recruit individuals at the beginning of their careers (16, 17). There were also 2 publications on a retrospective cohort (18, 19) and 5 case–control studies (20–24); some of the latter were part of the cohort studies already mentioned (20–22).
The findings of the EAACI position paper (14) and more recent studies can be summarized as follows: in 8 of these studies a history of atopy was a risk factor for asthma or respiratory symptoms (eTable 2). In 5 studies, a pre-existing sensitization to occupational allergens was identified as risk factor for respiratory symptoms (rhinitis and asthma). Three studies provided evidence that pre-existing bronchial hyperresponsiveness was associated in particular with subsequent onset of asthma or airway symptoms.
Only a few studies investigated further potential risk factors for the development of occupational asthma or exacerbation of existing asthma in the first years of work. These found that women were more frequently affected than men; active smoking and exposure to passive smoking at an early age were described as unfavorable prognostic factors.
Allergic rhinitis and typical occupational sensitization
As with asthma, pre-existing sensitization to ubiquitous allergens is the principal risk factor for occupational sensitization and new-onset allergic rhinitis (eTable 2). Occupational sensitization can either remain asymptomatic or lead to allergic rhinitis or to airway symptoms at work and subsequently to occupational asthma. The atopic march (from atopic eczema to allergic rhinitis and asthma) could not be confirmed in all cohort studies (25).
The 9 included publications on occupational skin diseases (eBox, eTable 3) showed history of atopic eczema (26, e24), a positive atopy score according to Diepgen et al. (27, 28, e17, e25), and wet work (4, 5, 27, 28, e26) to be the principal risk factors for occupational hand eczema (eTable 4). Various other indicators of atopic skin diathesis, such as history of flexural eczema or dry skin, were also risk factors for occupational hand eczema (27, e17, e27) (eTable 4). Only one study investigated evidence in clinical history of pre-existing contact allergies; it was associated with a significantly increased risk of onset of hand eczema (e17).
Diagnostic procedures were also investigated as predictors of occupational hand eczema. These included various skin function tests, some of which were found to be very sensitive (94%) regarding subsequent onset of hand eczema. However, these tests were judged unsuitable for clinical practice due to their poor specificity (24%) (e17).
In a few studies, the positive predictive values of individual risk factors for the development of occupational asthma, rhinitis, and hand eczema were calculated. They were found to be between 9 and 64% (Table 1).
Due to the high prevalence of atopic diseases and their possible consequences for patients and indirectly for society as a whole, career advice for young people predisposed to atopy is very important. The available literature gives only a small number of confirmed predictive factors; these include prior atopic diseases and asymptomatic sensitization to ubiquitous allergens.
Intuitively, one might conclude that all atopy and asthma patients should be excluded from occupations that entail relevant exposures. However, this can only be clearly recommended for patients with severe asthma or severe atopic eczema (e28). For other prior conditions, various studies show that this measure—quite apart from its ethical implications—would not be effective, because most individuals with atopy will not develop occupational asthma or rhinitis. For example, to prevent one case of occupational asthma, 3 to 10 atopy patients would have to be advised against work that entailed a risk (29, e29). In view of the high proportion of individuals with atopy in the general population, this is not useful as the sole basis for decisions in individual career advice. However, individuals who are specifically sensitized, before the beginning of training, to a substance found at the workplace that cannot reliably be avoided, and who develop specific symptoms (rhinitis, asthma, eczema) on contact with that substance, should be advised against pursuing the occupation in question.
In a German study (6), models for predicting an individual patient’s overall risk in the first years of employment were developed on the basis of epidemiological studies and made available online as a risk calculator (www.allergierisiko.de). The risk calculator shows clearly how strongly the individual risk of developing asthma in the first months of a high-risk occupation depends on other cofactors: in the absence of other risk factors for asthma, the risk factor atopy increases the risk of new-onset asthma by only 1.8 percentage points, from 0.5% to 2.3%. The risk calculator also indicates the following other risk factors for asthma:
- Female sex
- Higher socioeconomic status
- At least one parent with asthma or atopic dermatitis
- Exposure to passive smoking during puberty
- Not breastfed
- No siblings.
If a patient has all these other risk factors, the risk of new-onset asthma is 32% for individuals without atopy and 70% for those with atopy. Additional studies should investigate whether these predictions are reliable.
The available research indicates that rhinitis (e10, e30, e31) and hand eczema (26) are particularly likely to lead individuals to cease their occupation and avoid exposure. It is therefore advisable to examine young people with a risk profile for these conditions closely at the beginning of training in high-risk occupations, in order to begin appropriate secondary prevention such as early treatment and use of PPE promptly. This can prevent cessation of training and damage to health. Occupational physicians, and possibly also pulmonologists and dermatologists, are important partners in this. Young people with a risk profile in occupations such as those shown in Table 2 should be examined every 6 to 12 months during the first 2 years of training (14, e10, e32).
Recent studies indicate that monitoring programs and training measures can reduce the risk of occupational asthma (e2, e33–e36) and hand eczema (6–10). School-based interventions among high school–age students have shown that the use of virtual patients in the classroom can improve young people’s knowledge of occupational asthma and allergies in the long term (e37) (www.volle-puste.de). Training regarding skin protection and basic therapy in new workforce entrants has also been shown to be effective (e38). Without such measures, only around one-third of employees take preventive measures (e39). Secondary preventive measures, in contrast, do not seem to be as effective as complete avoidance of allergens (e40–e43). However, a recent study by Muñoz et al. was unable to confirm this (e44). It is important that thorough diagnostics be performed by a specialized physician before an individual is dismissed or hastily gives up his or her work. If occupational asthma is suspected, diagnostics should always also include patient self-monitoring of lung function for at least 3 weeks with and without occupational exposure (30). If allergic contact sensitization is suspected, epicutaneous tests should also be performed (e45).
The studies systematically summarized here show that the available data is rather scarce. In particular, there is a lack of long-term observational studies conducted in the general population and observing individuals from their choice of occupation through their first years of work. The studies conducted to date investigating high-risk occupations focused mainly on those working in occupations traditionally considered hazardous, such as nurses, hairdressers, animal laboratory employees, and bakers/pastry chefs. Very few studies included an unexposed comparison group. In addition, there is almost no research into non-occupational factors. Many of the available studies have methodological shortcomings such as excessively short follow-up periods, low participant numbers, or no appropriate statistical modeling.
The literature search was performed in the PubMed database only, as one would expect that being purely medical this subject would be addressed in publications listed in PubMed. Literature not published in journals was not viewed. It was only possible to include references in 4 languages. A few relevant studies may, therefore, not have been included. However, this would not have affected the outcome of the literature search significantly, as the findings of the available papers were generally consistent.
Approximately one-third of apprentices in Germany have an elevated risk of occupational asthma, allergies, and dermatitis. The individual predictive value of specific parameters is too low to advise all young atopy patients against entering particular occupations. Those with severe asthma or atopic eczema and clinically manifest sensitization that is relevant to certain occupations should avoid the occupations that entail a risk. All young atopy patients wishing to begin an occupation that entails a risk should be informed of the risk and of preventive measures beforehand and should be monitored every 6 to 12 months for the first 2 to 3 years after the beginning of exposure. In addition to allergy-specific history taking and general physical examinations, those with a history of allergies should receive skin prick tests for general and job-specific allergens, spirometry, and—in case of work-related respiratory symptoms—unspecific bronchial challenge tests (methacholine) (14). However, diagnostic testing for occupational allergy in patients without a history of allergic diseases (“prophetic testing”) is not indicated (e46).
The authors would like to thank the German Federal Ministry of Labor and Social Affairs for its funding for conduct of the SOLAR study, and the SOLAR study’s scientific panel for its advice.
Conflict of interest statement
Prof. Vogelberg was a member of various ALK-Abelló advisory boards.
Prof. Radon, Prof. Nowak, and Prof. Ruëff declare that no conflict of interest exists.
Manuscript received on 18 January 2016, revised version accepted on 14 April 2016.
Translated from the original German by Caroline Shimakawa-Devitt, M.A.
Prof. Dr. rer. biol. hum. Katja Radon
Center for International Health
Institute for Occupational, Social and Environmental Medicine
Munich University Hospital (LMU)
80336 München, Germany
For eReferences please refer to:
eBox, eTables, eFigure:
Comprehensive Pneumology Center, DZL, Deutsches Zentrum für Lungenforschung, München:
Prof. Dr. rer. biol. hum. Radon, Prof. Dr. med. Nowak
Department of Pediatrics, University Hospital Carl Gustav Carus, Dresden: Prof. Dr. med. Vogelberg
Department of Dermatology and Allergology, AllergieZENTRUM, Klinikum der Universität München:
Prof. Dr. med. Ruëff
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